Hybrid Transvaginal NOTES Nephrectomy: Postoperative Sexual Outcomes. A Three-center Matched Study

What is the applicability of tubal ligation with the vaginal natural orifice transluminal endoscopic surgery technique and its value in patient comfort?

OBJECTIVE

The aim of this study was to observe the feasibility of the tubal/adnexal approach using vaginal natural orifice transluminal endoscopic surgery and compare its contribution with surgeon ergonomics and postoperative patient comfort with that of conventional laparoscopy.

METHODS

We completed this study retrospectively with 47 patients. Patients were followed at their postoperative first month. We analyzed the usability of the vaginal natural orifice transluminal endoscopic surgery method over conventional laparoscopy by comparing the demographics, surgical data, and postoperative findings collected between the two groups.

RESULTS

Patients in the conventional laparoscopy group were older (39.1±3.3 years) than those in the vaginal natural orifice transluminal endoscopic surgery patient group (p=0.005). Pain intensity 24 h after surgery was lower in the vaginal natural orifice transluminal endoscopic surgery group (p=0.003), while sexual function and dyspareunia did not differ between the two groups in the first month. Patients in the vaginal natural orifice transluminal endoscopic surgery group were more relieved about painlessness and the comfort it brought than the conventional laparoscopy group (p=0.027, χ2=12.56).

CONCLUSION

Patients subjected to the vaginal natural orifice transluminal endoscopic surgery procedure showed higher levels of satisfaction, less postoperative pain, and greater comfort than those subjected to conventional laparoscopy.

Does transvaginal natural orifice transluminal endoscopic surgery affect female sexual function?: a prospective cohort study

BACKGROUND

To evaluate the effect of transvaginal natural orifice transluminal endoscopic surgery (vNOTES) on female sexual function.

METHODS

The trial was registered at the Chinese Clinical Trial Registry (ChiCTR2100050887, 07/09/2021). In this prospective cohort study, we prospectively analyzed the data of the female sexual function index (FSFI) questionnaire of 130 patients who underwent laparoscopy in Chengdu Women's and Children's Central Hospital due to gynecological benign diseases. The patients were assigned to the vNOTES group and the control group (underwent traditional laparoscopic surgery or transumbilical laparoendoscopic single-site surgery).

RESULTS

There were 4 cases dropout in the vNOTES group and 2 cases dropout in the control group. There was no difference in the ages (31.70 ± 5.02 vs. 30.37 ± 5.74, P>0.05), BMI (body mass index, 21.76 ± 3.16 vs. 23.30 ± 2.69, P>0.05), Education level, surgical types, and FSFI scores (22.31 ± 2.25 vs. 21.55 ± 3.38) between the vNOTES group and the control group before surgery. There was no difference in FSFI scores six months postoperation between the vNOTES group and the control group (21.61 ± 3.22 vs. 20.99 ± 3.26, P>0.05), and there was no difference in FSFI scores pre- and six months postoperation in vNOTES group (21.61 ± 3.22 vs. 22.31 ± 2.25, P>0.05). The time to start sexual life after surgery in the vNOTES group was later than that in the control group (39.34 ± 0.71 d versus 37.86 ± 0.69 d, P < 0.05).

CONCLUSIONS

vNOTES has no significant adverse effect on female sexual function, however, the time to start sexual life after vNOTES is later than that after trans-abdominal laparoscopy.

Cosmesis and feasibility of transvaginal natural orifice Specimen extraction (NOSE) for large organ specimen: a prospective pilot study

Background

This study aimed to evaluate cosmetic outcomes and feasibility of transvaginal natural orifice specimen extraction (NOSE) in patients who underwent laparoscopic or robotic surgery for the treatment of benign or malignant diseases of the kidney, liver, stomach, adrenal gland, and bladder.

Methods

This prospective study was conducted at a tertiary hospital between March 2015 and May 2020. The main outcome was cosmetic outcomes of scars assessed using the Patient and Observer Scar Assessment Scale (POSAS) 1 and 8 weeks after surgery. The secondary outcomes were postoperative pain, operating time, and complications. Sexual function was assessed using the Female Sexual Function Index (FSFI) questionnaire 6 months after surgery in 17 patients who were sexually active at the time of surgery.

Results

A total of 38 transvaginal NOSE procedures were performed for the extraction of 33 kidneys, 2 livers, 1 stomach, 1 adrenal gland, and 1 bladder. Observers rated pigmentation and relief scores as most deviant from normal skin (2.9 ± 1.7, 3.0 ± 2.1 at postoperative 1 week; 3.6 ± 1.9, 3.5 ± 2.2 at postoperative 8 weeks, respectively), but the overall scores of each item were low. The patients’ overall satisfaction with postoperative scars was high, and the mean scores for pain and itching were low, with significant improvement from the first week to the eighth week (P = 0.014 and P = 0.006, respectively). Patients also reported low scores on vaginal assessment items, indicating better symptoms, and bleeding improved significantly between the two time points (P = 0.001). Postoperative pain was reduced from moderate during the first 24 h after surgery to mild after 24 h. The mean operative time of the transvaginal NOSE procedure was 28.3 ± 13.3 min. No postoperative complications were associated with the procedure. The mean FSFI total score was 21.2 ± 8.7 (cutoff score for dysfunction is 21), with higher scores indicating better sexual functioning.

Conclusion

Transvaginal NOSE seems to be a feasible procedure with promising cosmetic benefits, for patients who undergo minimally invasive surgery for large organs including the kidney, liver, stomach, adrenal gland, and bladder. A prospective randomized clinical trial is needed to provide solid evidence to support transvaginal NOSE.

Trial registration:

This trial is registered at ClinicalTrials.gov (NCT05113134).

Ultra-minimally invasive surgery in gynecological patients: a review of the literature

In the last decade, Ultra-minimally invasive surgery (UMIS) including both minilaparoscopic (MH) and percutaneous (PH) endoscopic surgery achieved widespread use around the world. Despite UMIS has been reported as safe and feasible surgical procedure, most of the available data are drawn from retrospective studies, with a limited number of cases and heterogeneous surgical procedures included in the analysis. This literature review aimed to analyze the most methodologically valid studies concerning major gynecological surgeries performed in UMIS. A literature review was performed double blind from January to April 2021. The keywords ‘minilaparoscopy’; ‘ultra minimally invasive surgery’; ‘3 mm’; ‘percutaneous’; and ‘Hysterectomy’ were selected in Pubmed, Medscape, Scopus, and Google scholar search engines. PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) guidelines were followed for the drafting of the systematic review. The systematic literature research provided 298 studies, of which 9 fell within the inclusion criteria. Two hundred ninety-six total patients were included, 148 for both PH and MH groups. Median age (48 years), BMI (24 kg/m²), OT (90 min), EBL (50 ml), time to discharge (1 day), self scar evaluation (10/10), and VAS (3/10) were reported. The most frequent intraoperative complication in both the PH and MH groups was surgical bleeding. The UMIS approaches were feasible and safe even for complex gynecological procedures. Operative times and complications were superimposable to the “classical” minimally invasive approaches reported in the literature. The reported results apply only to experienced surgeons.

Transvaginal natural orifice specimen extraction surgery (NOSES) in 3D laparoscopic partial or radical nephrectomy: a preliminary study

Background

With the development of minimally invasive technology, more and more people pay attention to aesthetics of the wound after operation. This study is aim to introduce a new surgical technique of transvaginal natural orifice specimen extraction surgery (NOSES) in 3D laparoscopic partial or radical nephrectomy and evaluate the safety, feasibility and clinical effect.

Methods

Eleven patients who underwent 3D laparoscopic partial nephrectomy (n = 7) or radical nephrectomy (n = 4) and NOSES were included in this study. The surgical procedures and techniques, especially the NOSES operation, are reported in detail. In addition, the basic clinical data, perioperative related data, perioperative complications were analyzed.

Results

All 11 patients were performed successfully without conversion to open surgery. The mean total operative time was 133 (84, 150) min. NOSES time was 15 (13, 16) min, and the postoperative hospital stay was 5 (5, 5) d. The mean visual analogue score (VAS) was 3 (2, 4) point and 1 (0, 1) point at 24 h and 48 h after operation, respectively. No patient had recurrence, metastasis and death during the follow-up period of 3 to 17 months. The median Vancouver Scar Scale (VSS) was 1 (1, 1) point. The mean of Female Sexual Function Index (FSFI) was 21.60 (20.20, 21.60), 21.80 (19.80, 21.80) respectively between preoperative and postoperative 3 months, which has no statistical difference (P = 0.179). There was no statistical difference in the Pelvic Floor Distress Inventory-short form 20 (PFDI-20) score between preoperative and postoperative 3 months (P = 0.142).

Conclusions

Transvaginal NOSES is safe and feasible in 3D laparoscopic partial or radical nephrectomy. Furthermore, it results in low incision-related pain without affecting the pelvic floor and sexual function.

The Comparison of Transvaginal Natural Orifice Transluminal Endoscopic Surgery and Conventional Laparoscopy in Opportunistic Bilateral Salpingectomy for Permanent Female Sterilization

STUDY OBJECTIVE

To compare the transvaginal natural orifice transluminal endoscopic surgery (vNOTES) approach with conventional laparoscopy (CL) in opportunistic bilateral salpingectomy (BS) alone for permanent female sterilization as an opportunistic cancer prevention strategy.

DESIGN

Prospective cohort study.

SETTING

Two-centered tertiary hospitals.

PATIENTS

Ninety-six women with a nonprolapsed uterus seeking definitive surgical permanent contraception.

INTERVENTIONS

Patients were scheduled for BS and assigned to a study arm in a 2:1 fashion (CL:vNOTES allocation ratio) concerning patient's choice.

MEASUREMENTS AND MAIN RESULTS

Patients were followed at their postoperative first week and first month. The visual analog score (VAS), Patient Global Impression of Improvement, and Female Sexual Function Index scales were used to assess the pain, patient satisfaction, and discomfort/pain after vaginal penetration, respectively. Patients who underwent to vNOTES had a significantly higher number of previous abdominal surgery (median difference, 1.97; 95% confidence interval [CI], 1.12-3.48; p = .016). Compared with CL, vNOTES was associated with lower 6-hour (rate ratio [RR], 0.63; 95% CI, 0.50-0.77) and 24-hour (RR, 0.33; 95% CI, 0.23-0.46) postoperative VAS scores and less amount of postoperative analgesics (RR, 0.54; 95% CI, 0.36-0.78). The slope of change in postoperative VAS scores was in a shorter time in the vNOTES group (RR, 0.47; 95% CI, 0.36-0.60). The rate of postoperative improvement was higher in the vNOTES group than the CL group at the postoperative first week (87.5% vs 68.2%, χ² = 4.232, p = .032) and first month (96.9% vs 87.9%, χ² = 2.091, p = .140). The rate of patients reporting postoperative decline in Female Sexual Function Index /pain scores (RR, 0.97; 95% CI, 0.47-1.96) was found to be similar in both of the study groups, and no postoperative complication was observed in either group.

CONCLUSION

Women seeking permanent sterilization and who underwent BS for ovarian cancer risk reduction purposes had higher satisfaction, less postoperative pain, lower analgesic requirement, and similar surgical outcomes in the vNOTES group than the CL group, even in patients with previous surgeries and a nonprolapsed uterus. vNOTES approach could be the preferred method for the opportunistic BS in female sterilization.

A new and practical surgical technique of transvaginal natural orifice specimen extraction surgery (NOSES) in laparoscopic nephroureterectomy-an initial clinical experience

OBJECTIVE

To explore the safety, feasibility and clinical effect of transvaginal natural orifice specimen extraction surgery (NOSES) in 3D laparoscopic nephroureterectomy (LNU) for upper tract urothelial carcinoma (UTUC).

METHODS

A retrospective analysis was made of 16 female patients who underwent 3D LNU and NOSES in the Department of Urology, Cancer Hospital, Chinese Academy of Medical Sciences from June 2019 to December 2020. The basic clinical data, perioperative related data, perioperative complications, visual analogue pain score (VAS), postoperative scar assessment questionnaire (PSAQ) at 3 months, female pelvic floor dysfunction questionnaire (PFDI-20) and female sexual function index questionnaire (FSFI) at preoperative and postoperative 3 months were analyzed and evaluated.

RESULTS

The surgery was successfully completed in all 16 patients, and none of them was converted to open surgery. No postoperative complications, such as abdominal incision-related infection. No cases of local recurrence and distant metastasis were observed during follow-up of 3 to 21 months. The VAS scores at 24 h and 48 h after operation were 2.9 ± 0.7, 1.3 ± 0.6, respectively. PSAQ scores at 3 months after operation were 34.3 ± 3.3. PFDI-20 scores of women preoperative and postoperative 3 months were 6.25 ± 1.75, 6.3 ± 1.8, respectively, and the difference was not statistically significant (p = 0.924). There was no significant difference in FSFI scores between preoperative and postoperative 3 months (p = 0.892).

CONCLUSION

Transvaginal NOSES in 3D LNU for UTUC is safe, feasible and practical. The successful development of this technique has laid a solid foundation for further clinical application and promotion.

Managing female sexual dysfunction

OBJECTIVE

Provide an overview of sexual dysfunction in female urologic cancer patients, approaches for assessing sexual problems, and interventions to treat sexual dysfunction in this patient population.

METHODS

A review of the literature in urologic oncology was conducted. Research on other female pelvic cancers with similar treatments was also reviewed.

RESULTS

Sexual health is an important element of women's quality of life that is often not discussed and problems remain unaddressed. Urologic cancer treatments commonly result in sexual dysfunction (e.g., dyspareunia, vaginal dryness, problems with orgasm) in female patients, although more research is necessary to understand the impact of non-surgical treatments (e.g., radiation, chemotherapy, immunotherapy). As such, provider teams should complete necessary screening for sexual dysfunction during and after treatment. The 5 A's model (i.e., Ask, Advise, Assess, Assist, Arrange Follow-Up) provides a helpful guide for communicating about and addressing sexual health concerns with patients during the screening process. If it is determined that referral for further assessment and treatment of sexual dysfunction is needed, a number of non-pharmacologic (e.g., pelvic floor physical therapy; psychosexual counseling) and pharmacologic treatment approaches are available.

CONCLUSION

Sexual dysfunction is common in female urologic cancer survivors. Routine assessment and appropriate referral are essential for high quality patient care.

Transvaginal hybrid-NOTES vs. traditional laparoscopic sigmoid resection for diverticulitis: a short-term comparative study

The aim was to compare short-term results of transvaginal hybrid-NOTES (NSR) with traditional laparoscopic technique in sigmoid resection (LSR) in cases of diverticulitis. Natural Orifice Transluminal Endoscopic Surgery has been evolved as a minimally invasive procedure to reduce the operative trauma due to the absence of specimen extraction through the abdominal wall causing less postoperative pain, and shorter hospital stay. Despite the increasing use and published case series of NSR for diverticulitis as a laparoscopic procedure with transvaginal stapling and specimen extraction, there are no studies comparing this procedure with LSR. Twenty NSR patients operated at the Cologne-Merheim Medical Center have been documented and compared with 20 female LSR patients matched for body mass index, American Society of Anesthesiologists-classification (ASA), Hansen/Stock classification, and age. To ensure comparability regarding peri- and postoperative care, only procedures performed by the same surgeon were included. Procedural time, intra- and postoperative complications, conversion rate, postoperative pain, the duration of an epidural catheter, analgesic consumption, and postoperative length of hospital stay were analyzed. There were no significant differences in the sum of pain levels (p = 0.930), length of procedure (p = 0.079), intra- and postoperative complications, as well as duration of an epidural catheter. On the contrary, there were significant positive effects for NSR on morphine requirement at day seven and eight (p = 0.019 and p = 0.035 respectively) as well as the postoperative length of hospital stay (p = 0.031). This retrospective study reveals significant positive effects for NSR compared to LSR regarding length of hospital stay as well as morphine consumption after removal of the epidural catheter, whereas there were no significant differences in complication rate and procedural time. In summary, NSR is an adequate alternative to traditional laparoscopic sigmoid resection considering the surgeons experience and the patient’s personal preferences.

Single-port laparoscopy-assisted vaginal repair of a cesarean scar defect: a single-center retrospective study

Supplemental Digital Content is available in the text

Background:

The incidence of uterine cesarean scar defect (niche) is high, and some patients require surgery. Single-port laparoscopy can reduce post-operative pain, and provide better cosmetic effects. This study was performed to evaluate the safety and superiority of single-port laparoscopy-assisted vaginal repair of uterine cesarean scar defect (niche) in women after cesarean section.

Methods:

This study included 74 patients who were diagnosed with uterine cesarean niche at the Shanghai First Maternity and Infant Hospital from January 2013 to June 2015. Thirty-seven patients underwent single-port laparoscopy-assisted vaginal surgery as the case group, and the remaining patients underwent vaginal repair surgery as the control group. We collected data from the inpatient and follow-up medical records. The clinical characteristics of these two groups were compared. The odds ratios and 95% confidential intervals were calculated for each variable by univariate and multivariate analyses.

Results:

Patients who underwent single-port laparoscopy-assisted vaginal repair had a significantly longer operation time (2.3 [2.0–2.7] vs. 2.0 [1.6–2.3] h, P = 0.015), shorter gas passage time (1.2 [1.0–1.5] vs. 1.7 [1.0–2.0] days, P = 0.012), shorter hospital stay (3.1 [3.0–4.0] vs. 4.5 [4.0–6.0] days, P = 0.019), and fewer complications (0 vs. 4 cases). Univariate analysis showed that depth of the niche (P = 0.021) the mild adhesiolysis score (P = 0.035) and moderate adhesiolysis score (P = 0.013) were associated with the bladder injury. Multivariate analysis showed that the moderate adhesiolysis score (P = 0.029; 95% confidence interval, 1.318–3.526) was the strongest independent predictor of bladder injury.

Conclusion:

This study confirmed the safety and superiority of single-port laparoscopy-assisted vaginal repair of uterine cesarean scars.

Laparoscopic Versus Open Partial Nephrectomy: A Systemic Review and Meta-Analysis of Surgical, Oncological, and Functional Outcomes

Purpose

To summarize and analyze the current evidence about surgical, oncological, and functional outcomes between laparoscopic partial nephrectomy (LPN) and open partial nephrectomy (OPN).

Materials and Methods

Through a systematical search of multiple scientific databases in March 2020, we performed a systematic review and cumulative meta-analysis. Meanwhile, we assessed the quality of the relevant evidence according to the framework in the Cochrane Handbook for Systematic Reviews of Interventions.

Results

A total of 26 studies with 8095 patients were included. There was no statistical difference between the LPN and OPN in the terms of operation time (p=0.13), intraoperative complications (p=0.94), recurrence (p=0.56), cancer-specific survival (p=0.72), disease-free survival (p=0.72), and variations of estimated glomerular filtration rate (p=0.31). The LPN group had significantly less estimated blood loss (P<0.00001), lower blood transfusion (p=0.04), shorter length of hospital stay (p<0.00001), lower total (p=0.03) and postoperative complications (p=0.02), higher positive surgical margin (p=0.005), higher overall survival (p<0.00001), and less increased serum creatinine (p=0.002). The subgroup analysis showed that no clinically meaningful differences were found for T1a tumors in terms of operation time (p=0.11) and positive surgical margin (p=0.23). In addition, the subgroup analysis also suggested that less estimated blood loss (p<0.0001) and shorter length of hospital stay (p<0.00001) were associated with the LPN group for T1a tumors.

Conclusions

This meta-analysis revealed that the LPN is a feasible and safe alternative to the OPN with comparable surgical, oncologic, and functional outcomes. However, the results should be applied prudently in the clinic because of the low quality of evidence. Further quality studies are needed to evaluate the effectiveness LPN and its postoperative quality of life compared with OPN.

Transvaginal minimally invasive approach: An update on safety from an anatomical, anatomopathological and clinical point of view

INTRODUCTION

The aim of this work was to analyze the transvaginal approach in minimally invasive surgery in terms of anatomical, histopathological and functional characteristics, to show the safety of this surgical approach.

METHODS

Anatomical study was first conducted by dissection on fresh cadavers of adult women in order to measure the distance between the vaginal incision and the ureters, rectum and hypogastric nerves. In parallel, an anatomopathological study detailed and compared the macroscopic and histological characteristics of the anterior and posterior surfaces of vaginal samples obtained from cadavers and patients in the context of a hysterectomy for benign pathology. Finally, patients who underwent a transvaginal approach nephrectomy or transplantation were retrospectively enrolled for a clinical examination and an evaluation of their sexuality.

RESULTS

The anatomical study conducted on seventeen cadavers showed that the posterior vaginal fornix was remote from the major structures of the pelvis such as rectum, ureters, hypogastric plexus, which allowed a safe incision. Mechanical tests further demonstrated that the posterior vaginal fornix was more extensible than the anterior and histological features showed no major vascular or nervous structures. Ten patients were included in the retrospective clinical study. Long-term follow up showed no negative impact on the texture of the vagina or satisfaction from sexual intercourse.

CONCLUSIONS

Anatomical, histological and functional data supported that transvaginal approach by posterior vagina fornix incision is a minimally invasive surgery that can be performed safely and effectively by a skilled surgeon in cases with a specific surgical indication for this approach.

A systematic review on the cost evaluation of two different laparoscopic surgical techniques among 996 appendectomies from a single center

Acute appendicitis is one of the main indications for urgent surgery representing a high-volume procedure worldwide. The current spending review in Italy (and not only in this country) affects the health service and warrants care regarding the use of different surgical devices. The aim of our study is to perform a cost evaluation, comparing the use of endoloops and staplers in complicated acute appendicitis (phlegmonous and gangrenous), taking into consideration the cost of the device in relation to the management of any associated postoperative complications. We retrospectively evaluated 996 laparoscopic appendectomies of adult patients performed in the Emergency General Surgery-St. Orsola University Hospital in Bologna (Italy). Surgical procedures together with the related choice of using endoloops or staplers were performed by attending surgeons or resident surgeons supervised by a tutor. A systematic review was performed to compare our outcomes with those reported in the literature. In our experience, the routine use of endoloop leads to a real estimated saving of 375€ for each performed laparoscopic appendectomy, even considering post-operative complications. Comparing endoloop and stapler groups, the total number of complications is significantly lower in the endoloop group. Our systematic review confirmed these findings even if the superiority of one technique has not been proved yet. Our analysis shows that the routine use of endoloop is safe in most patients affected by acute appendicitis, even when complicated, and it is a cost-effective device even when taking into consideration extra costs for potential post-operative complications.

Sexuality in women with endometriosis: a critical narrative review

Endometriosis is a chronic gynecological disease that generally affects young and sexually active women in different stages of their development and sexual life. Because endometriosis affects about 5-10% of women in reproductive age, it is possible to estimate that about 2-4% of those who are sexually active may suffer from sexual dysfunction caused by this disease. Surgical and pharmacological treatments of endometriosis can improve the patient's sexual function in the medium and long term, but not necessarily lead to a definitive resolution of the sexual issue. For this reason, the ideal treatment should be conducted by a multidisciplinary team, with the aim to improve overall sexual functioning and not only to reduce the painful symptoms during intercourse. In light of these considerations, the aim of this narrative review was to provide a general overview about the impact of endometriosis on sexuality of women affected and the effectiveness of surgical and pharmacological treatments in improving sexual function.

How well do software assistants for minimally invasive partial nephrectomy meet surgeon information needs? A cognitive task analysis and literature review study

INTRODUCTION

Intraoperative software assistance is gaining increasing importance in laparoscopic and robot-assisted surgery. Within the user-centred development process of such systems, the first question to be asked is: What information does the surgeon need and when does he or she need it? In this article, we present an approach to investigate these surgeon information needs for minimally invasive partial nephrectomy and compare these needs to the relevant surgical computer assistance literature.

MATERIALS AND METHODS

First, we conducted a literature-based hierarchical task analysis of the surgical procedure. This task analysis was taken as a basis for a qualitative in-depth interview study with nine experienced surgical urologists. The study employed a cognitive task analysis method to elicit surgeons' information needs during minimally invasive partial nephrectomy. Finally, a systematic literature search was conducted to review proposed software assistance solutions for minimally invasive partial nephrectomy. The review focused on what information the solutions present to the surgeon and what phase of the surgery they aim to support.

RESULTS

The task analysis yielded a workflow description for minimally invasive partial nephrectomy. During the subsequent interview study, we identified three challenging phases of the procedure, which may particularly benefit from software assistance. These phases are I. Hilar and vascular management, II. Tumour excision, and III. Repair of the renal defects. Between these phases, 25 individual challenges were found which define the surgeon information needs. The literature review identified 34 relevant publications, all of which aim to support the surgeon in hilar and vascular management (phase I) or tumour excision (phase II).

CONCLUSION

The work presented in this article identified unmet surgeon information needs in minimally invasive partial nephrectomy. Namely, our results suggest that future solutions should address the repair of renal defects (phase III) or put more focus on the renal collecting system as a critical anatomical structure.

The methods and techniques of identifying renal pedicle vessels during retroperitoneal laparoscopic radical and partial nephrectomy

Background

Retroperitoneal laparoscopic radical and partial nephrectomy (RLRN and RLPN) have become the preferred modes of management for renal malignancy. One of the most critical steps in the RLRN and RLPN process is to seek and control the renal pedicle. The current study focuses on introducing methods and techniques that can help quickly and accurately identify the renal pedicle vessels during RLRN and RLPN.

Methods

RLRNs and RLPNs were performed for 292 cases in our hospital from November 2014 to January 2017. Different measures were adopted to seek and manage bilateral renal pedicle vessels. All operation procedures were performed by the following three steps: dissection, opening, and clamping. For the left lateral, after the perirenal fat in the dorsal and lateral side was fully dissected, the kidney was pushed toward the ventral side. The renal artery was visible when opening the dense bulging connective tissue, which was located in the middle of the dorsal interior of the kidney. Then, the renal artery was clamped with a Hem-o-lok or the Bulldog clamp. For the right kidney pedicles, the inferior vena cava was first identified and then dissipated upward. When the inferior vena cava was not visible, it was often the location of the right renal artery. The treatment for the artery was the same as for the left renal artery. Relevant clinical characteristics of patients, such as operative time, intraoperative blood loss, and duration of postoperative drainage, were analyzed retrospectively. The three-step method of identifying renal pedicle vessels during retroperitoneal laparoscopic radical and partial nephrectomy was evaluated.

Results

All operations were successfully accomplished with satisfying results, during which the artery could be controlled quickly, and no cases were converted to open surgery due to severe bleeding of renal pedicle vessels. There were no complications involving renal vessels during the entire study. The mean operative times were (81.9 ± 19.71) min and (88.2 ± 21.28) min for RLRN and RLPN, with an average intraoperative blood loss of (91.7 ± 47.10) ml and (62.4 ± 47.45) ml, respectively. The warm ischemia time for RLPN was (19.3 ± 5.6) min. The postoperative drainage-tube was removed within (4.5 ± 1.29) d (RLRN) and (4.6 ± 1.98) d (RLPN); the mean postoperative hospital stay times were (7.0 ± 2.4) d and (5.9 ± 1.98) d, respectively.

Conclusion

The three-step method of identifying renal pedicle vessels during RLRN and RLPN is direct and feasible, and it may help simplify the operating procedure and improve the safety of the surgery. It may be of great practical application value in the clinical field.

Electronic supplementary material

The online version of this article (10.1186/s12957-019-1580-1) contains supplementary material, which is available to authorized users.

Minimally Invasive Surgery in Pediatric Urology: Adaptations and New Frontiers

As the frontiers of minimally invasive surgery (MIS) continue to expand, the availability and implementation of new technology in pediatric urology are increasing. MIS is already an integral part of pediatric urology, but there is still much more potential change to come as both recent and upcoming advances in laparoscopic and robotic surgery are surveyed.

Tumor markers of uterine cervical cancer: a new scenario to guide surgical practice?

Since the introduction of Pap smear screening, the incidence and mortality of cervical cancer (CC) have been reduced drastically in USA and in other western states. Nevertheless, CC still remains the main cause of death from gynecological cancer in developing countries where screening programs are scant or inexistent. This evidence highlights the efficacy of screening, and the wide use of Human Papilloma Viruses (HPV) vaccines in developed countries. More and more people are, consequentially, undergoing a screening procedure, usually combined with HPV DNA test, increasing the early diagnosis of intraepithelial HPV-related lesions. The long transit time from early cervical lesion to invasive cancer provides an opportunity to identify pre-cancerous lesions where treatment result is maximum. In fact, when an invasive CC occurs, the overall survival rate strictly depends on stage of disease with an average survival of 70% at 5 years. Under the pressure of this reality, researches have made efforts to individuate cancer markers as indicator of specific cancer events. Some markers were showed to be able to detect those intraepithelial lesions have more chance to evolve to invasive forms (p16^ink4a, p16, E-cadherin, Ki67, pRb, p53). Markers such as CEA, SCC-Ag, CD44, have been developed to detect invasive forms. Although cancer markers actually are not used only for early diagnosis, they may be useful in others fields of application such as evaluation and monitoring of treatments to improve diagnosis and treatment of CC.

Exploring the umbilical and vaginal port during minimally invasive surgery

This article focuses on the anatomy, literature, and our own experiences in an effort to assist in the decision-making process of choosing between an umbilical or vaginal port. Umbilical access is more familiar to general surgeons; it is thicker than the transvaginal entry, and has more nerve endings and sensory innervations. This combination increases tissue damage and pain in the umbilical port site. The vaginal route requires prophylactic antibiotics, a Foley catheter, and a period of postoperative sexual abstinence. Removal of large specimens is a challenge in traditional laparoscopy. Recently, there has been increased interest in going beyond traditional laparoscopy by using the navel in single-incision and port-reduction techniques. The benefits for removal of surgical specimens by colpotomy are not new. There is increasing interest in techniques that use vaginotomy in multifunctional ways, as described under the names of culdolaparoscopy, minilaparoscopy-assisted natural orifice surgery, and natural orifice transluminal endoscopic surgery. Both the navel and the transvaginal accesses are safe and convenient to use in the hands of experienced laparoscopic surgeons. The umbilical site has been successfully used in laparoscopy as an entry and extraction port. Vaginal entry and extraction is associated with a lower risk of incisional hernias, less postoperative pain, and excellent cosmetic results.

Fertility sparing surgery for stage IA type I and G2 endometrial cancer in reproductive-aged patients: evidence-based approach and future perspectives

Fertility-sparing surgery (FSS) in reproductive-age patients affected by endometrial cancer (EC) gained growing attention in the last decade, although the first reports were already published in 1990-2000s. Nevertheless, only few patients undergoing FSS for stage I, type I EC had been reported in each case series, without a robust multicenter study. In the available literature there are even fewer reported cases of conservative treatment of Stage IA and G2 EC. Considering these important gaps in our current knowledge, the purpose of this review was to summarize the available evidence about conservative treatments for stage IA type I and G2 EC, to improve the pretreatment counseling for reproductive-age patients. According to our overview, women who have low-risk disease (G1 or G2, endometrioid histotype confined to the endometrium) are candidates for progestin therapy. In addition, FSS could be considered a valid option for reproductive-aged patients with stage IA type I and G2 EC. Nevertheless, we solicit new trials to clarify the medium- and long-term outcomes in this kind of patients.

Preoperative work-up for definition of lymph node risk involvement in early stage endometrial cancer: 5-year follow-up

This prospective cohort study aimed to analyze the accuracy of magnetic resonance imaging (MRI) and hysteroscopic excisional biopsy (HEB) for predicting the low- and high-risk patients with endometrial carcinoma for nodal involvement at preoperative evaluation. From January 2005 to December 2006, all patients with a diagnosis of endometrial carcinoma were prospectively included in the study and underwent pelvic MRI and HEB. The pelvic MRI (without contrast) was aimed to evaluate the extent of myometrial invasion (MI < 50%, MI ≥ 50%), the possible involvement of cervical stroma, the ovarian, and lymph nodes status. HEB was performed under general anesthesia, retrieving multiple biopsies through a 5-mm, monopolar, loop electrode. According to our data analysis, the integration of MRI and HEB showed an elevated accuracy and high rates of sensitivity (85.0%), specificity (88.5%), negative predictive value (91.9%) and positive predictive value (79.0%) in identifying low-risk patients who do not need comprehensive surgical staging.